Summary

An 82-year-old male with multiple comorbidities, including previous laparotomies, had a suprapubic catheter (SPC) inserted
under guidance with ultrasound and a flexible cystoscope. Three months following the procedure, having returned for a flexible
cystoscopy for ongoing bladder pain syndrome, he became peritonitic postoperatively.

A CT scan and subsequent laparotomy confirmed the SPC to be passing through a section of terminal ileum. The bowel was resected
and he recovered well after a long hospital admission. A literature search found this delayed presentation of bowel perforation
following SPC insertion to be rare, with only a few other cases reported. In particular, previous abdominal surgery increases
the risk of this complication. This case serves as a reminder of the rare but potentially significant risk of SPC insertion
and unusually highlights that this may not present immediately.

Footnotes

Contributors TS contributed to the conception and design of the study. TS and NS were involved in the planning and data acquisition. TS,
NS and EW were responsible for the conduct and reporting. Drafting article was done by TS and EW. All authors equally contributed
to the revision of the article, final approval and agreed to be accountable for the work.